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THE APPLICANT HEREBY CERTIFIES: - <br /> 1. That he/she has read all the provisions of this application,aid that the description inched inn"application are correct to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for personal injury or damage to property which may arise out of the wade described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of San Jbagitm or any depart,oTkial or employee thereof;he shall <br /> defend,indemnify and holdthem and each of them harmless for such claim;and <br /> 5. That work shall be performed by the applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Encroachnient Permit and <br /> 6. That if permission is granted as requested,he agrees to do the wort described in accordance with all tears,conditions and restriction of this and any <br /> a ttac lie f,included eS general or special Ili provisions. <br /> Signature of Applicant-Title Date <br /> FIELD INSPECTOR COMMENTS <br /> »>>EXISTING CONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: Nene ❑ Dirt Gravel ❑ Aggregate Base ❑ P—d(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awayfrom Pavement El Towards Pavement El Flat <br /> 3. PIPES: None [V Existing-Type It <br /> Other pipes in neighborhood: Yes ❑ No Approaches ❑ Cures Thain ❑ Size <br /> Attachment to neighbor'$rpe: Yes ❑ No ,It <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DUKE: Yes ❑ No <br /> 6. BARRIERS alongRight-of-Way V` <br /> 7. DITCH Yes ❑ No x If Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR Jf COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with 1=�--"Min Dei#h A C.over 3/4"A.B. <br /> Notes <br /> 2. PIPES: Length of Pipe Required: Ft.and Diameter of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No — <br /> DRAINAGE INLET REQUIRED Yes ❑ No 9, <br /> Total Length: (with proposed) Total Number of Storm Draft Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Min.Depth A.C.over "Min Depth 3/4"A.B. <br /> Measuring Fed in length and Fed in width <br /> FEES <br /> i <br /> vew y Encroachment Permit base fee............................$85.00 <br /> tion <br /> Driveway w/or w/o pipe.................................................$95.00 ❑ Paved fientage..............................$100.00+0.46ht <br /> ❑ <br /> Driveway w/boxCulverL...............................................$155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98M <br /> Cour¢er\Computer,c:\Access\Application for Pesmits0riveway and Paved Frontage Pap 2 of 2 Revised 8/2000 <br />